Intranasal stimulation for enhanced release of ocular mucins and other tear proteins

ABSTRACT

Described here are devices and methods for increasing ocular mucin and other tear protein release using intranasally delivered electrical stimulation. Generally, the devices may deliver electrical stimulation to the nasal mucosa. Intranasal stimulation may trigger degranulation of conjunctival goblet cells, which in turn releases secretory mucins into the tear fluid. The intranasal stimulation may also trigger release of lysozyme, lactoferrin, and other tear proteins into the aqueous layer of the tear film. The methods may further comprise obtaining feedback relating to the efficacy of the delivered electrical stimulation by measuring impedance or an electromyogram (EMG) signal.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. application Ser. No. 15/367,030 filed on Dec. 1, 2016, which claims priority to U.S. Provisional Application No. 62/376,834 filed on Aug. 18, 2016, U.S. Provisional Application No. 62/330,744 filed on May 2, 2016, U.S. Provisional Application No. 62/321,170 filed on Apr. 11, 2016, and U.S. Provisional Application No. 62/263,498 filed on Dec. 4, 2015. Each of the foregoing disclosures is hereby incorporated by reference in its entirety.

FIELD

Described herein are devices and methods for increasing ocular mucin and other tear protein release using intranasally delivered electrical stimulation. The devices may deliver electrical stimulation to the nasal mucosa to trigger degranulation of conjunctival goblet cells, which in turn releases secretory mucins into the tear fluid. The intranasal stimulation may also trigger release of lysozyme, lactoferrin, and other tear proteins into the aqueous layer of the tear film. The methods may further comprise obtaining feedback relating to the efficacy of the delivered electrical stimulation by measuring impedance or an electromyogram (EMG) signal.

BACKGROUND

Dry eye is thought to stem from abnormalities of the tear film on the surface of the eye. The tear film includes three layers, an inner mucus layer, an outer lipid layer, and an aqueous layer between them. The mucus layer, which is primarily composed of mucins, is the thinnest layer and functions to adhere the tear film to the eye.

Mucins are high molecular weight glycoproteins that have various functions. Some mucins are secreted into the mucous layer while others form the glycocalyx (transmembrane mucins), which is the specific structure that adheres the tear film to the eye. The glycocalyx is partially embedded in the lipid bilayer of corneal and conjunctival epithelial cells and forms a hydrophilic network that binds secreted mucins in the mucus layer to these cells. Additionally, the mucins in the mucus layer and glycocalyx are believed to attract water, thereby decreasing the surface tension of the tear film and facilitating the even spread of the aqueous layer on the eye, which in turn may protect the eye from pathogens and make the ocular surface less susceptible to damage. Mucins that have been detected in the tear film include MUC1, MUC2, MUC4, MUC5AC, MUC7, MUC13, MUC15, MUC16, and MUC 17. Transmembrane mucins include MUC1, MUC4, MUC13, MUC15, MUC16, and MUC17. Secreted mucins include MUC2, MUC5AC, and MUC7, which can be further classified as gel-forming or soluble. MUC5AC has been identified as a secreted, gel-forming mucin. Mucins found on the ocular surface are primarily produced by goblet cells (e.g., secreted mucin MUC5AC), apical cells of the conjunctiva and cornea (e.g., transmembrane mucins MUC1, MUC2 and MUC4), and the lacrimal gland (e.g., secreted mucin MUC7). In addition to mucins, the lacrimal gland secretes proteins into the aqueous layer that promote spreading of the tear film and that help maintain a healthy environment on the ocular surface. Exemplary proteins include lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E.

Decreased mucin and tear protein levels have been associated with dry eye. Common treatment approaches are typically palliative in nature, attempting to supplement the patient's natural tears or improve the residence time of the limited tear volume already present on the ocular surface (Dry Eye Workshop 2007. The Epidemiology of Dry Eye Disease. Ocul. Sur. 2007; 5(2): 93-107). These treatment approaches have had limited success. It would therefore be desirable to have an improved treatment that increases mucin and other tear protein levels in the tear film.

SUMMARY

Described herein are devices and methods for increasing mucin release on the ocular surface of a subject. The devices may be stimulator devices configured to contact the nasal mucosa and intranasally deliver an electrical stimulus. In some instances, the stimulator devices are configured as handheld stimulators. The electrical stimulus is capable of increasing the mucin concentration in the tear film by, e.g., triggering degranulation of goblet cells in the conjunctiva of the eye.

The methods for increasing mucin on an ocular surface of a subject generally comprise intranasally delivering an electrical stimulation to the subject, and stimulating release of an ocular mucin, where the released ocular mucin improves a condition of the eye. The intranasally delivered electrical stimulation may be delivered for at least 10 seconds, and in some instances, for at least three minutes, and may be repeated as desired. The electrical stimulation is generally intranasally delivered to the nasal mucosa. Additionally or alternatively, the intranasal delivery of electrical stimulation may include delivering an electrical stimulus comprising a waveform having on and off periods.

Electrical stimulation may be intranasally delivered using a stimulator, where the stimulator comprises a stimulator body and a stimulator probe, and further where the stimulator probe comprises at least one nasal insertion prong. A portion of the nasal insertion prong may be placed in contact with the nasal mucosa as part of the stimulation delivery process. The nasal insertion prong may include various types of electrodes, however, it may be useful for the electrode to comprise a hydrogel. The stimulator body may be sized for holding in one hand. Some variations of the stimulator probe may include two nasal insertion prongs. In these variations, the two nasal insertion prongs may be biased toward each other, and the bias used to promote stimulation of the septum of the nasal cavity and/or to hold the stimulator in the nose during intranasal delivery of the electrical stimulation.

The intranasally delivered electrical stimulation may stimulate release of an ocular mucin. Exemplary ocular mucins include without limitation, MUC1, MUC2, MUC4, MUC5AC, MUC7, MUC13, MUC15, MUC16, and MUC 17. Some of these mucins, e.g., MUC5AC, may be released by stimulating degranulation of goblet cells. Various parameters of the electrical stimulation waveforms may be tailored to achieve goblet cell degranulation or release of a particular type of ocular mucin from other cells, e.g., apical cells or acinar cells. In some instances, intranasal stimulation may decrease the concentration of certain inflammatory mediators in the tear film.

The intranasally delivered electrical stimulation may also be used in methods that increase the release of tear proteins in the aqueous layer of the tear film or the concentration of tear proteins in the aqueous layer of the tear film. These tear proteins include without limitation, lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E.

The methods for increasing mucin and other tear proteins on the ocular surface may further include identifying an optimal stimulation location for intranasally delivering the electrical stimulation. The optimal stimulation location may be identified via impedance monitoring. Additionally or alternatively, the optimal stimulation location may be identified by obtaining feedback from an electromyogram (EMG) signal from a facial muscle near the nose, cheeks, or around the eyes. The impedance and EMG signals may be measured intranasally using the same device that delivers the electrical stimulation. In other instances, the impedance and EMG signals are measured by an extranasal device. One or more parameters of the electrical stimulation waveforms may be tailored or optimized to achieve release of the tear proteins from secretory vesicles of the lacrimal gland.

Methods for treating dry eye are also described herein. The methods generally include intranasally delivering electrical stimulation to a subject afflicted with dry eye; obtaining feedback relating to the efficacy of the delivered electrical stimulation by measuring impedance or an electromyogram (EMG) signal from a facial muscle near the nose, cheeks, or around the eyes of the subject; formulating a treatment plan based on the feedback; and continuing intranasal delivery of the electrical stimulation according to the treatment plan, where the delivered electrical stimulation increases the release of a tear protein to treat the dry eye of the subject. The tear protein can be mucin, lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E, or a combination thereof.

Additionally or alternatively, the methods for treating dry eye may include determining whether a subject afflicted with dry eye is deficient in a tear protein on an ocular surface, and based on the tear protein found to be deficient, intranasally delivering an electrical stimulation to the subject, where one or more parameters of the intranasally delivered electrical stimulation is selected based upon the deficient tear protein, and where the intranasally delivered electrical stimulation is effective to increase the release or the concentration of the deficient tear protein on the ocular surface. The tear protein can be mucin, lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E, or a combination thereof. In some instances, the methods may include determining a type of dry eye in a subject and intranasally delivering to the subject an electrical stimulation according to a treatment plan based on the determined type of dry eye, e.g., mild dry eye, moderate dry eye, or severe dry eye.

Intranasally delivered electrical stimulation and release of ocular mucins and other tear proteins may improve dry eye and ocular inflammation, as well as other ocular conditions. The methods described herein may further be combined with additional treatments, such as the application of artificial tears to the ocular surface, use of one or more punctum plugs, and/or the application of an active agent to the ocular surface. Here, for example, the active agent may comprise one more antibacterial agents, one or more anti-inflammatory agents, one or more antihistamines, one or more steroids, or combinations thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic diagram showing the layers of the tear film on the corneal surface.

FIG. 2 illustrates the anatomy of the lower eyelid, eye, and conjunctiva.

FIG. 3 is a schematic diagram of a goblet cell.

FIGS. 4A, 4B, 4C, 4D, 4E show perspective, front, back, cut-away back, and cut-away side views, respectively, of an illustrative variation of a stimulator.

FIG. 5 shows a block diagram schematically representing a variation of a stimulator.

FIGS. 6A, 6B, and 6C depict back, front, and perspective views, respectively, of an exemplary stimulator probe suitable for the stimulators described here.

FIG. 7 shows a cross-sectional view of an exemplary stimulator positioned in the nasal cavities.

FIGS. 8A and 8B show perspective and front views, respectively, of the stimulator of FIGS. 4A-4E with an attached cap.

FIGS. 9A-9D depict portions of an exemplary stimulator system comprising a stimulator and a base station. FIG. 9A shows a front view of the stimulator body docked in the base station, while FIGS. 9B, 9C, and 9D depict side, back, and top views, respectively, of the base station.

FIGS. 10A-10D illustrate exemplary amplitude modulation waveform parameters.

FIGS. 11A-11D and FIG. 12 illustrate exemplary pulse width modulations.

FIG. 13A shows an exemplary handheld stimulator inserted into a subject's nose.

FIG. 13B shows the handheld stimulator positioned on the exterior of a subject's nose.

FIG. 14 is a graph of the data provided in Table 1 relating to goblet cell density (GCD) ratio (degranulated/non-degranulated) in the conjunctiva of dry eye and healthy subjects stained with MUC5AC.

FIG. 15 is a graph of the data provided in Table 2 relating to degranulated goblet cell densities in the inferior and temporal bulbar conjunctiva stained with MUC5AC in control and dry eye subjects.

FIG. 16 is a graph of the data provided in Table 3 relating to goblet cell density (GCD) ratio (degranulated/non-degranulated) in the inferior and temporal bulbar conjunctiva of dry eye patients stained with MUC5AC.

FIG. 17 is a graph of the data provided in Table 4 relating to goblet cell density (GCD) ratio (degranulated/non-degranulated) in the conjunctiva of dry eye and healthy subjects stained with PAS.

FIG. 18 is a graph of the data provided in Table 5 relating to goblet cell density (GCD) ratio (degranulated/non-degranulated) in the inferior and temporal bulbar conjunctiva of dry eye patients stained with PAS.

FIG. 19 present graphs of the data provided in Table 6 relating to tear meniscus height changes before and after extranasal and intranasal stimulation application in dry eye and control subjects.

FIG. 20 presents optical coherence tomography images showing the change in height in the right eye (top) and left eye (bottom) before (left) and after (right) the intranasal application of stimulation in one dry eye subject with Sjögren's syndrome.

FIG. 21 is a graph of the data provided in Table 7 relating to decreases in MMP-9 concentrations in the tear fluid of control and dry eye subjects before and after application of extranasal and intranasal stimulation.

FIG. 22 is a graph illustrating the decrease in IL-8 concentrations in the tear fluid of control and dry eye subjects before and after application of extranasal and intranasal stimulation.

FIG. 23 is a schematic diagram of how ocular mucins function together with the glycocalyx to reduce inflammation on the eye surface.

DETAILED DESCRIPTION

Described here are devices and methods for increasing tear protein release using intranasal stimulation. Tear proteins include mucins, which are secreted into the mucin layer of the tear film, and proteins secreted by the lacrimal gland into the aqueous layer of the tear film. In some variations, the devices and methods are configured to deliver an electrical stimulus to the nasal mucosa to cause mucin release, e.g., by stimulating degranulation of goblet cells. Increased mucin production may be useful in 1) adhering the tear film to the ocular surface; 2) enhancing lubrication of the ocular surface; 3) preventing break-up of the tear film; 4) capturing dust, allergens, and bacteria, which in turn may reduce the sensory input that drives the inflammatory/histamine response in the eye; and 5) preventing desiccation of corneal and/or conjunctival epithelial cells. In other variations, the devices and methods are configured to deliver an electrical stimulus to the nasal mucosa to cause secretion of other tear proteins from the lacrimal gland into the aqueous layer of the tear film, e.g., lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E. Increased tear protein secretion may be useful in promoting spreading of the tear film and controlling infectious agents on the ocular surface, as well as and regulating the osmotic balance of the ocular surface.

The tear film maintains the transparency and health of the cornea, and is generally comprised of three layers, including an outer lipid layer 100, a middle aqueous layer 102, and an inner mucus layer 104, as shown in FIG. 1, although it may also be thought as having a surface lipid component and then phases of aqueous with differing concentrations of mucins suspended throughout. Regardless, the tear film in its entirety provides a smooth optical interface needed for good visual acuity, supplies nutrients to the eye and flushes away waste products, and helps to protect against shear forces generated when blinking and during eye movements, as well as protects against environmental exposure and foreign bodies.

The inner mucus layer is primary comprised of mucins. Goblet cells, which are modified simple columnar epithelial cells found in the conjunctiva of the eye (e.g., bulbar conjunctiva 200 shown in FIG. 2), produce secretory mucins such as MUC5AC. Other types of mucins are produced by acinar cells of the lacrimal gland and apical cells of the conjunctiva and cornea. Referring to FIG. 3, goblet cell 300 has a nucleus 302 and organelles, e.g., Golgi apparatus 304 and rough endoplasmic reticulum 306 at the base of the cell. Secretory vesicles/granules containing mucin 308 are contained within the top portion of the cell, and give the cell its goblet shape when the granules 308 expand. Microvilli 310 at the cell tip increase the surface area of the cell for secretion.

In patients with dye eye, the proper amount of mucins in the tear film may be lacking. The abnormal mucin production may be due to systemic diseases (e.g., Sjögren's syndrome), medications, or other causes. In some variations, the methods described herein may use application of intranasal stimulation to increase mucin release into the tear film. Additionally or alternatively, the methods described herein may use intranasal stimulation to increase mucin release by triggering goblet cell degranulation (i.e., release of mucin-containing vesicles/granules).

Intranasal stimulation may in part increase mucin secretion through modulating parasympathetic innervation of goblet cells in the conjunctiva. More particularly, afferent parasympathetic stimulation with particular waveforms (described in detail elsewhere herein) may increase the secretory drive of goblet cells. In some variations, intranasal stimulation may increase mucin release by stimulating the pterygopalatine ganglion (PPG) via the greater petrosal nerve. In other variations, repeated and/or sustained intranasal stimulation over a period of time may improve release of mucin from goblet cells (goblet cell degranulation) and/or increase the number/density of goblet cells in the conjunctiva.

Devices and Systems

Generally, the devices and methods described herein may comprise a stimulator configured to deliver an electrical stimulus to the inner cavity of the nose. The instrument consists of four distinct parts: 1) A reusable base unit, which produces the electrical stimulation waveform, 2) A disposable tip assembly that inserts into the nasal cavity and stimulates the target intranasal tissue, 3) A reusable cover to protect the tip assembly, 4) A charger, which recharges the battery inside the base unit. Some variations of the stimulation systems described here may comprise a handheld stimulator. FIGS. 4A, 4B, 4C, 4D, 4E show perspective, front, back, cut-away back, and cut-away side views, respectively, of an illustrative variation of a handheld stimulator 400, respectively. FIG. 5 shows a block diagram schematically representing the stimulator 400. As shown in FIGS. 4A-4E, the stimulator 400 may comprise a stimulator body 402 and a stimulator probe 404. Generally, the stimulator body 402 may be configured to generate a stimulus that may be delivered to the subject. The stimulator body 402 may comprise a front housing 438, back housing 440, and proximal housing 442, which may fit together to define a body cavity 454. The body cavity 454 may contain a control subsystem 436 and a power source 452, which together may generate and control the stimulus.

The stimulator body 402 may comprise a user interface 530 comprising one or more operating mechanisms to adjust one or more parameters of the stimulus. The operating mechanisms may provide information to the control subsystem 436, which may comprise a processor 532, memory 534, and/or stimulation subsystem 536. In some variations, the operating mechanisms may comprise first and second buttons 414 and 416. In some variations, pressing the first button 414 may turn on the stimulator and/or change one or more parameters of the stimulus (e.g., increase the intensity of the stimulus, change the stimulation pattern, or the like), while pressing the second button 416 may turn off the stimulator and/or change one or more parameters of the stimulus (e.g., decrease the intensity of the stimulus, change the stimulation pattern, or the like). Additionally or alternatively, the user interface may comprise one or more feedback elements (e.g., based on light, sound, vibration, or the like). As shown, the user feedback elements may comprise light-based indicators 418, which may provide information to the user, as described in more detail below.

In the variation shown in FIGS. 4A-4E, the user interface may be configured for use by the subject receiving the intranasal stimulation. However in other variations, the stimulators may comprise an interface configured for use by a person other than the subject receiving the intranasal stimulation, such as a medical professional. For example, a stimulator may comprise a remote interface operable at a distance from the stimulator body. The remote interface may be connected to the stimulator body wirelessly or in a wired manner (e.g., via a cable). The remote interface may allow the stimulator to be turned on/off and or may be used to change one or more parameters of the stimulation. A remote interface may be desirable, for example, so a medical professional can adjust the stimulus parameters when intranasal stimulation is delivered at the medical professional's office. In some variations, the stimulators may be configured to be controlled by both the subject receiving the intranasal stimulation and another person (e.g., a medical professional). For example, a stimulator may comprise a user interface on the stimulator body, as shown in FIGS. 4A-4E, and a remote interface.

The stimulus may be delivered to a subject via the stimulator probe 404. In some variations the stimulator body 402 and stimulator probe 404 may be reversibly attachable. Some or all of the stimulator 400 may be disposable. For example, in some variations the stimulator body may be permanently attached to the stimulator probe, and the entire stimulator may be disposable. In other variations, one or more portions of the stimulator 400 may be reusable. For example, in variations where the stimulator probe 404 is releasably connected to the stimulator body 402, the stimulator body 402 may be reusable, and the stimulator probe 404 may be disposable and periodically replaced.

The stimulator probe 404 may comprise at least one nasal insertion prong, which may be configured to be at least partially inserted into the nasal cavity of a subject. In the handheld stimulator variation shown in FIGS. 4A-4E, the stimulator probe 404 may comprise two nasal insertion prongs 406 and 408. The stimulator probe 404 may further comprise ridges 420, which may allow the subject to more easily grip the probe 404. Each nasal insertion prong may comprise at least one electrode. As shown, the probe 404 may comprise a first electrode 410 on nasal insertion prong 406 and a second electrode 412 on nasal insertion prong 408. As shown in the cut-away view of the stimulator 400 in FIG. 4D, the electrodes 410 and 412 may be connected to leads 430 and 432 located within prongs 406 and 408, respectively. The leads 430 and 432 may in turn be connected to connectors 422 and 424, respectively. Connectors 422 and 424 may extend through lumens 508 and 510 in the proximal housing 442, and may connect directly or indirectly to the control subsystem 436 and power source 452. As such, the electrical stimulus may travel from the control subsystem 436 through the connectors 422 and 424, through the leads 430 and 432, and through the electrodes 410 and 412.

In some variations, the nasal insertion prongs may be parallel when not inserted into the nose of a subject, but may have sufficient flexibility to allow the prongs to self-align to the desired stimulation location when inserted into a user's nasal cavities. In other variations of stimulators comprising two nasal insertion prongs, however, the nasal insertion prongs may not be parallel to each other when not inserted into the nose of a subject; that is, the nasal insertion prongs may be positioned at an angle relative to each other. For example, FIGS. 6A-6C show stimulator probe 600 comprising first and second nasal insertion prongs 602 and 604, respectively, connected to a base member 606. The nasal insertion prongs 602 and 604 may be connected to the base member 606 such that they are angled toward each other. In some variations, the angle between the nasal insertion prongs may be adjustable. For example, the nasal insertion prongs may be biased toward a configuration in which the nasal insertion prongs are at an angle relative to each other, but may be movable to a parallel configuration. When the prongs are inserted into nasal cavities to position tissue (e.g., a nasal septum) between the prongs, the prongs may be rotated away from each other prior to insertion into the nasal cavities. Once positioned in the nasal cavities, the force may be removed and the return bias may rotate the prongs toward each other, and the return bias of the stimulator probe may press the distal ends of the nasal insertion prongs against tissue. This may help to increase electrode apposition with tissue, and in some instances may act to hold the stimulator probe in place relative to tissue. To remove the stimulator probe from tissue, the prongs may again be rotated away from each other to release the tissue positioned between the prongs.

In some variations in which the stimulator comprises two nasal insertion prongs biased toward each other, the return bias may be sufficient to hold the stimulator in place. In these variations, once positioned in the nasal cavities, the distal ends of the nasal insertion prongs may press against tissue with sufficient force to allow for hands-free use—that is, the user may not need to hold the stimulator in order for the electrodes to remain in apposition with the target tissue. This may improve ease of use. In other variations, the return bias may be sufficient to reduce unintended movement of the nasal insertion prongs while inserted, while still requiring the stimulator to be held.

The devices (and systems) described herein may additionally or alternatively also comprise other features to allow hands-free or reduced-handling use. For example, the system may comprise a strap configured to be placed around a user's head and attached to the stimulator to hold the stimulator in place during stimulation. The strap may be removably attachable to the stimulator, or in other variations may be permanently attached to the stimulator. In some variations of stimulators configured for hands-free use, the stimulators may be configured to be inserted and/or removed by a user. In other variations, the stimulators may be configured to be inserted/removed by a medical professional.

For example, FIG. 7 depicts a cross-sectional view of a subject's nose having a septum 708 and nostrils 710 and 712 having a variation of a hands-free stimulator 700 located therein. As shown there, the stimulator 700 may comprise a clip 702, a first stimulator unit 704 attached to a first end of the clip 702, and a second stimulator unit 706 attached to a second end of the clip 702. Generally, the clip 702 may be configured to temporarily connect the stimulator 700 to a nasal septum 708 of a subject, which may position the first stimulator unit 704 in the first nostril 710 and the second stimulator unit 706 in the second nostril 712.

In some variations, the clip 702 may comprise a u-shaped portion 714 configured to receive and clamp to a portion of the nasal septum 708. This engagement between the clip 702 and the nasal septum 708 may limit advancement of the stimulator 700 into the nose (e.g., to prevent over-insertion of the stimulator 700). The clip 702 may exert sufficient pressure on the septum 708 so as to resist removal of the stimulator 700 from the nose. Accordingly, the clip 702 may allow the stimulator to be positioned in the nose of a subject, and the subject may wear the stimulator without needing to actively hold the stimulator in the nose. The clip 702 may be removed by flexing the clip 702 to disengage it from the septum. As such, the subject may be able to insert and remove the stimulator 700 him- or herself. In some variations, the clip 702 may be at least partially formed from one or more shape memory materials (e.g., a nickel-titanium alloy), such that the clip 702 may be deformed to disengage the clip 702 from the septum 708 and may return to its original shape. In some variations an exterior portion of the clip 702 may be formed from one or more insulating materials, such as described herein (e.g., PTFE, silicone, combinations thereof, or the like), and an interior portion may include an electrically conductive core (e.g., a wire of any suitable metal, such as silver, stainless steel, platinum, alloys thereof, or the like) electrically connecting the first stimulator unit 704 to the second stimulator unit 706. In these variations, the insulating outer portion of the clip 702 may prevent inadvertent electrical stimulation between the clip 702 and the subject.

Generally, each stimulator unit may comprise one or more electrodes 716. In some variations, it may be desirable for the stimulator units to comprise a radially expandable structure that may expand to contact the nasal mucosa when inserted into the nostrils. While shown in FIG. 7 as being formed from an expandable wire mesh/braid electrode, each electrode 716 may be configured in any suitable manner. For example, in some variations the electrodes may comprise a hydrogel. Additionally or alternatively, it may be desirable for the stimulator units to comprise a smooth surface to prevent tissue abrasion. The stimulator may be configured such that the electrodes 716 are placed in contact with any suitable tissue structure or structures (e.g., the nasal mucosa above the columella, such as the nasal mucosa superior to the columella (e.g., the nasal mucosa near the interface between the nasal bone and the upper lateral cartilage) when the clip 702 is connected to the nasal septum.

Generally, the first 704 and/or second 706 stimulator units may comprise a housing 720, which may comprise a control subsystem having a processor, a stimulation subsystem, and a memory. In some variations the control subsystem may have a detection subsystem. Additionally or alternatively, the stimulator may comprise a communication subsystem. The stimulator circuitry may be housed in a single housing 720 (e.g., a housing 720 of the first stimulator unit 704 or a housing 720 of the second stimulator unit), or may be divided between multiple housings (e.g., a housing 720 of the first stimulator unit 704 and a housing 720 of the second stimulator unit). In some variations, the stimulator 700 may comprise a power source (e.g., a battery) (not shown). In other variations, the stimulator 700 may be powered wirelessly (e.g., via power received from a coil 718 or other antenna).

In some variations, the stimulators described here may comprise a cap to protect the stimulator probe. For example, FIGS. 8A and 8B show perspective and front views, respectively, of stimulator 400 with an attached cap 800. As shown there, the cap 800 may fit over the stimulator probe 404, which may protect the probe from contamination. More particularly, it may be desirable for the cap to protect the nasal insertion prongs, and especially the electrodes, from contamination. The systems described here may additionally or alternatively comprise a base station. The base station may be configured to releasably connect to one or more portions of the stimulator, and may be configured to perform one or more functions when connected to the stimulator. FIGS. 9A-9D depict a portion of a stimulator system comprising a base station 900 as described here. FIG. 9A shows a front view the stimulator body 902 docked in the base station 900, while FIGS. 9B, 9C, and 9D depict side, back, and top views of the base station 900, respectively. In variations where the stimulator body 902 comprises a rechargeable power source (such as a rechargeable battery, capacitor, or the like), the base station 900 may be configured to recharge the rechargeable power source.

Other variations and features of stimulator systems, devices, and their method of use suitable for employment in the methods described herein are described in U.S. patent application Ser. No. 14/256,915, filed Apr. 18, 2014, and titled “NASAL STIMULATION DEVICES AND METHODS”; in U.S. patent application Ser. No. 14/630,471, filed on Feb. 24, 2015, and titled “POLYMER FORMULATIONS FOR NASOLACRIMAL STIMULATION”; in U.S. patent application Ser. No. 14/920,860, filed Oct. 22, 2015, and titled “STIMULATION DEVICES AND METHODS FOR TREATING DRY EYE”; and in U.S. patent application Ser. No. 14/920,852, filed Oct. 22, 2015, and titled “IMPLANTABLE NASAL STIMULATOR SYSTEMS AND METHODS,” each of which is hereby incorporated by reference in its entirety.

Methods

Described herein are methods for increasing mucin and other tear proteins on an ocular surface of a subject. The methods generally include intranasally delivering an electrical stimulation to the subject, e.g., to the nasal mucosa of the subject. The intranasally delivered electrical stimulation may stimulate release of one or more ocular mucins to thereby improve a condition of the eye. In some instances, the intranasally delivered electrical stimulation stimulates or increases mucin release by stimulating/triggering degranulation of goblet cells in the conjunctiva of the eye. Additionally or alternatively, the intranasally delivered electrical stimulation may help to increase tear volume on the eye, e.g., by increasing the volume of the aqueous layer. Tear meniscus height (TMH) measurements can be used assess tear volume. Additionally or alternatively, the intranasally delivered electrical stimulation may be useful in decreasing the concentration of inflammatory mediators in the tear film, or decreasing a particular type of inflammatory mediator, e.g., MMP-9 or IL-8, in the tear film.

Release of Ocular Mucins

The stimulators and methods described herein may deliver waveforms configured to stimulate release of one more ocular mucins, as further described below. In some variations, the waveforms may be pulse-based. The waveforms may be configured to stimulate tissue on both sides of the nose, or the waveforms may be configured to stimulate tissue on a single side of the nose. In other variations, the waveform may comprise symmetric biphasic pulses. The waveform may be programmed to include any suitable parameters (e.g., frequency, pulse width, amplitude) in order to enhance or trigger mucin release. In addition to the waveforms described herein, exemplary waveforms that may be used for intranasal stimulation are described in U.S. patent application Ser. No. 14/809,109, filed Jul. 24, 2015, and titled “STIMULATION PATTERNS FOR TREATING DRY EYE,” which is hereby incorporated by reference in its entirety.

Electrical stimulation may be intranasally delivered for at least 5 minutes, at least 4 minutes, at least 3 minutes, at least 2 minutes, at least 1 minute, at least 30 seconds, at least 15 seconds, at least 10 seconds, or at least 5 seconds. In one variation, the electrical stimulation may be intranasally delivered for a duration of 3 minutes or at least 3 minutes. In other variations, the electrical stimulation may be intranasally delivered for a duration ranging from 30 seconds to one 1 minute, from 30 seconds to 1.5 minutes (90 seconds), from 30 seconds to 2 minutes (120 seconds), from 30 seconds to 2.5 minutes (150 seconds), or from 30 seconds to 3 minutes (180 seconds). The electrical stimulation may be repeated any number of times using the same waveform or a different waveform.

Generally, the stimulus may comprise a waveform of less than about 200 Hz. In some of these variations, the frequency is preferably between about 10 Hz and about 200 Hz. In some of these variations, the frequency is preferably between about 30 Hz and about 150 Hz. In others of these variations, the frequency is preferably between about 50 Hz and about 80 Hz. In others of these variations, the frequency is preferably between about 30 Hz and about 60 Hz. In some variations, the frequency may be about 1.5 Hz, about 10.25 Hz, about 70 Hz, about 150 Hz, about 25 Hz, about 27.5 Hz, about 30 Hz, about 32.5 Hz, about 35 Hz, about 37.5 Hz, about 40 Hz, about 42.5 Hz, about 45 Hz, about 47.5 Hz, about 50 Hz, about 52.5 Hz, about 55 Hz, about 57.5 Hz, about 60 Hz, about 62.5 Hz, or about 65 Hz.

Generally, when the stimulus comprises a biphasic pulse and the first phase of the biphasic pulse is current-controlled, the first phase may preferably have an amplitude between about 1.0 mA and about 10 mA. Amplitudes within these ranges may be high enough to stimulate targeted tissue, but sufficiently low as to avoid any significant heating of tissue, ablation of tissue, or the like. In some variations the amplitude may be between about 1.0 mA and about 5.0 mA. In other variations, the first phase may have an amplitude of about 0.1 mA, about 0.2 mA, about 0.3 mA, about 0.4 mA, about 0.5 mA, about 0.6 mA, about 0.7 mA, about 0.8 mA, about 0.9 mA, or about 1.0 mA. In some variations, the amplitude may be variable. For example, the amplitude may vary between about 1.3 mA and about 1.5 mA, about 2.2 mA and about 2.5 mA, about 3.2 mA and about 3.7 mA, about 4.3 mA and about 5.0 mA. When the first phase of a biphasic pulse is voltage-controlled, the first phase may preferably have an amplitude between about 10 mV and about 100 V.

When a stimulator is configured to deliver a pulse-based waveform, in some variations, the amplitude of the pulses may be constant over time. In other variations, the amplitude of the pulses may vary over time. This may reduce subject accommodation to the stimulation. In some variations, the amplitude of pulses may increase (linearly, exponentially, etc.) from a minimum value to a maximum value, drop to the minimum value, and repeat as necessary. In some variations, the amplitude of the pulses may vary according to a sinusoidal profile. In another variation, as illustrated in FIG. 10A, the amplitude may periodically increase from a baseline amplitude (A) to a higher amplitude (B) for a single pulse. In yet another variation, as illustrated in FIGS. 10B-10C, the amplitude of the pulses may follow a periodically increasing and decreasing pattern between two lower amplitudes (A, B), and periodically increase to a higher amplitude (C) for a single pulse (FIG. 10B) or for a plurality of pulses (e.g., two pulses) (FIG. 10C). In yet another variation, as illustrated in FIG. 10D, a higher amplitude pulse (or pulses) may be preceded by a brief pause (i.e., no current delivery). Each of these types of amplitude modulation may be implemented alone or in combination with any other type of amplitude modulation, and may reduce subject accommodation.

In some variations in which the amplitude varies over time, the amplitude may vary at a frequency suitable for reducing subject accommodation or increasing subject comfort, such as between about 0.1 Hz and about 5 Hz, between about 1 Hz and about 5 Hz, between about 1 Hz and 2 Hz, between about 2 Hz and 3 Hz, between about 3 Hz and 4 Hz, or about 4 Hz and about 5 Hz. In some variation, the amplitude may vary at a frequency of about 1.0 Hz, about 1.1 Hz, about 1.2 Hz, about 1.3 Hz, about 1.4 Hz, about 1.5 Hz, about 1.6 Hz, about 1.7 Hz, about 1.8 Hz, about 1.9 Hz, about 2.0 Hz, about 2.1 Hz, about 2.2 Hz, about 2.3 Hz, about 2.4 Hz, about 2.5 Hz, about 2.6 Hz, about 2.7 Hz, about 2.8 Hz, about 2.9 Hz, about 3.0 Hz, about 3.1 Hz, about 3.2 Hz, about 3.3 Hz about 3.4 Hz, about 3.5 Hz, about 3.6 Hz, about 3.7 Hz, about 3.8 Hz, about 3.9 Hz, or about 4.0 Hz. In other variations, the stimulation waveform may be a modulated high frequency signal (e.g., sinusoidal), which may be modulated at a beat frequency of the ranges described above. In such variations, the carrier frequency may be between about 100 Hz and about 100 kHz.

When the stimulus comprises a biphasic pulse, the first phase may preferably have a pulse width between about 1 μs and about 10 ms. In some of these variations, the pulse width may be between about 10 μs and about 100 μs. In other variations, the pulse width may be between about 100 μs and about 1 ms. In yet other variations, the pulse width may be between about 0 μs and about 300 μs. In yet other variations, the pulse width may be between about 0 μs and 500 μs.

In some variations, the pulse width may be constant over time. In other variations, the pulse width may vary over time. Pulse width modulation over time may increase the efficacy and/or comfort of the stimulation. In some variations, the pulse width may increase (linearly, exponentially, etc.) from a minimum value to a maximum value, drop to the minimum value, and repeat as necessary. In some variations, the pulse width may vary according to a sinusoidal profile. In another variation, as illustrated in FIG. 11A, the pulse width may periodically increase from a baseline pulse width (A) to a longer pulse width (B) for a single pulse. In yet another variation, as illustrated in FIGS. 11B-11C, the pulse width may follow a periodically increasing and decreasing pattern between two shorter pulse widths (A, B), and periodically lengthen to a longer pulse width (C) for a single pulse (FIG. 11B) or for a plurality of pulses (e.g., two pulses) (FIG. 11C). In yet another variation, as illustrated in FIG. 11D, a longer pulse width pulse (or pulses) may be preceded by a brief pause (i.e., no current delivery). Each of these types of pulse width modulation may be implemented alone or in combination with any other type of pulse width modulation. In any form of pulse width modulation, the pulse width may vary at any suitable frequency. In some variations the pulse width may vary at about 0.1 Hz, about 0.2 Hz, about 0.3 Hz, about 0.4 Hz, about 0.5 Hz, about 0.6 Hz, about 0.7 Hz, about 0.8 Hz, about 0.9 Hz, about 1 Hz, about 1.1 Hz, about 1.2 Hz, about 1.3 Hz, about 1.4 Hz, or about 1.5 Hz. In some variations, modulation of the pulse width at a rate between about 0.5 Hz and 1 Hz may be desirable to increase subject comfort during stimulation.

In some variations, the increase and decrease of pulse width may be defined by a function implemented by the stimulator. For example, the pulse width may be defined by a function such that the pulse width varies exponentially. In one variation, the function defining pulse width may comprise two phases—a first phase during which the pulse width of the leading pulse increases over time, and a second phase during which the pulse width of the leading pulse decreases over time. During the first phase, the pulse width of the leading pulse approaches the maximum pulse width according to an exponential function, where at time t, PW{t} is defined by the equation

${{PW}\left\{ t \right\}} = {\left( {{PW}_{\max} - {PW}_{\min}} \right)\left( {1 - e^{- {(\frac{t}{\tau})}}} \right)}$

where PW_(max) is the maximum allowed pulse width, PW_(min) is the minimum allowed pulse width, and τ is a time constant.

Once a predetermined amount of time has elapsed (a multiple of time constant τ), the pulse width modulation may enter the second phase. During the second phase, the pulse width of the leading pulse exponentially decays from its maximum value to a minimum value following the exponential equation

${{PW}\left\{ t \right\}} = {\left( {{PW}_{\max} - {PW}_{\min}} \right){\left( e^{- {(\frac{t}{\tau})}} \right).}}$

After a predetermined amount of time has elapsed (a multiple of time constant τ), the pulse width modulation may re-enter the first phase, and the cycle may repeat. The pulse width of the secondary (charge balancing) pulse is increased and decreased accordingly to retain charge full balancing. PWmax, PWmin, and τ may have any suitable values to achieve the pulse widths described herein, but in one example the waveform may have a PWmax of 300 μs, PW_(min) of 0 μs, and τ of ⅕ μs. In other variations, for example, PWmax, may be about 100 μs, about 200 μs, about 300 μs, about 400 μs, or about 500 μs; PW_(min) may be about 0 μs, about 10 μs, about 50 μs, or about 100 μs; and τ may be about ⅓ μs, about ¼ μs, about ⅕ μs, or about ⅙ μs. An exemplary function defining exponentially increasing and decaying pulse widths is shown in FIG. 12.

In some instances, the waveforms may be delivered in a continuous fashion, while in other instances, the waveforms may be delivered in a non-continuous fashion having on periods and off periods. Exemplary on/off durations include without limitation, 1 second on/1 second off, 1 second on/2 seconds off, 2 seconds on/1 seconds off, 5 seconds on/5 seconds off, 0.2 seconds on/0.8 seconds off, less than 1 second on/less than 10 seconds off. Non-continuous delivery with on and off periods may help to reduce subject accommodation and/or may be more effective than continuous delivery in causing mucin release.

Some variations of the methods described herein may comprise adjusting the waveform parameters based on feedback. In some variations the feedback may help to adjust the stimulus to be maximally effective in causing mucin release. Additionally or alternatively, the feedback may help to adjust the stimulus to prevent accommodation while limiting unpleasant sensations, such as a feeling of needing to sneeze.

The stimulators described herein may be used to intranasally deliver an electrical stimulation to increase release of one or more ocular mucins in the tear film, as previously stated. The methods may comprise intranasally delivering the stimulation to trigger goblet cell degranulation, mucin secretion from corneal, conjunctival, and/or apical cells into the tear film and/or glycocalyx. The intranasally delivered stimulation may also be used to promote sustained increases in mucin content of tears.

Ocular mucins include without limitation, MUC1, MUC2, MUC4, MUC5AC, MUC7, MUC13, MUC15, MUC16, and MUC 17. These ocular mucins may further be characterized as secreted mucins and transmembrane mucins. Exemplary secreted mucins are MUC2, MUC5AC, and MUC7. Exemplary transmembane mucins include MUC1, MUC4, MUC13, MUC15, MUC16, and MUC17. In some variations, the intranasally delivered electrical stimulation may be used to increase release of secreted mucin MUC5AC. Referring to the Examples, the study described in Example 1 demonstrated that intranasally delivered electrical stimulation increases the release of MUC5AC by stimulating degranulation of conjunctival goblet cells. Differences between healthy (control) subjects and those with dry eye were noted by histology (not shown) from conjunctival samples obtained by impression cytology and then stained for MUC5AC and by Periodic acid-Schiff (PAS), and by a comparison of ratios of degranulated to non-degranulated cells in the samples obtained before and after sham (extranasal) stimulation and intranasal stimulation. Upon staining, non-degranulated goblet cells were typically defined by their uniform size, intact cell borders, and intracellularly packaged mucins, while degranulated goblet cells were characterized by disrupted cell borders and scattered mucin granules. In some instances, PAS and MUC5AC stained specimens revealed clusters of degranulated goblet cells after intranasal stimulation. These clusters were not observed in cytology specimens taken at baseline and after extranasal stimulation. The stimulator used for such stimulation was similar to the device described in FIGS. 4A-4E and FIG. 5.

Specifically, the results obtained from MUC5AC staining indicated that the ratio of degranulated to non-degranulated goblet cell densities from subjects with dry eye was significantly higher after intranasal stimulation (4.71±4.48) compared to those taken at baseline (0.74±0.62, p<0.001) and after sham stimulation (0.57±0.54, p<0.001). See Table 1 in Example 1 for a complete listing of results after stimulation. PAS staining also demonstrated a significant increase in the ratio of degranulated to non-degranulated goblet cell densities after the delivery of intranasal stimulation in dry eye subjects (2.02±1.41) compared to those taken at baseline (0.73±0.36, p=0.001) and after sham stimulation (0.69±0.39, p=0.001). See Table 4 in Example 1 for a complete listing of results after stimulation.

Additional results obtained from inferior bulbar (IB) conjunctiva and temporal bulbar (TB) conjunctiva cytology specimens taken from all study participants and stained for MUC5AC revealed a significantly higher ratio of degranulated to non-degranulated goblet cells after intranasal stimulation (IB: 2.28±1.27 and TB: 1.81±1.01) compared to baseline (IB: 0.56±0.55, p=0.015) (TB: 0.56±0.32, p=0.003) and extranasal sham application (IB: 0.37±0.29, p=0.001) (TB: 0.39±0.33, p=0.001). When the same analysis was repeated in the dry eye or control groups, the ratio was significantly higher after intranasal stimulation than the baseline ratio and ratio after extranasal application in both groups (p<0.05). Moreover, while control subjects had a higher ratio of degranulated to non-degranulated goblet cells at baseline (0.75±0.52) compared to the dry eye group (0.41±0.27), the ratio became slightly higher in dry eye (2.04±1.12 vs. 1.99±1.21 in control) after intranasal stimulation application. A significant increase in the mean degranulated goblet cell density was also observed after intranasal stimulation. There was no significant difference between the IB or TB conjunctiva locations in terms of the effectiveness of the intranasal stimulation application on conjunctival goblet cell secretory response.

Data obtained from a single center, single-arm, study that included 15 dry eye subjects (22 eyes) specifically relating to morphological goblet cell changes before and after three minutes of intranasal stimulation showed a significant reduction in goblet cell area and perimeter. These results are provided in Example 4. Other image data that was obtained (not shown) before and after stimulation demonstrated that ocular goblet cells are smaller post nasal stimulation, indicating that ocular mucins are being released from the conjunctiva right on the eye and not just the conjunctiva of the eye lid.

In some variations, the intranasally delivered electrical stimulation may be used to increase release of a transmembrane mucin. For example, the intranasally delivered electrical stimulation may be used to increase release of MUC1, MUC4, MUC13, MUC15, MUC16, MUC17, or combinations thereof. Referring to FIG. 23, these membrane-associated mucins form a dense barrier in the glycocalyx at the epithelial tear film interface. In turn, this barrier prevents pathogen penetrance and is a lubricating surface that allows lid epithelia to glide over the corneal epithelia without adherence. The secreted mucins generally move easily over the glycocalyx mucins because both have anionic character that creates repulsive forces between them. In other variations, the intranasally delivered electrical stimulation may be used to increase release of an ocular mucin from acinar cells of the lacrimal gland or apical cells of the conjunctiva and cornea.

In general, the ocular glycocalyx in combination with other mucins provides a covering over the ocular surface, and helps to shield the ocular surface from bacteria, dust, and allergens, as previously stated. Given that intranasal stimulation may stimulate release of mucin from goblet cells, and may stimulate release of proteins in the lacrimal tears, a complete glycocalyx may be formed that may be beneficial to the healing process of corneal/conjunctival tissue. With a complete glycocalyx, symptoms due to allergy and/or eye dryness may be reduced. Mucin further functions as lubricant and/or cushion between the ocular surface and the eye lids that helps protect against scratching of the ocular surface. Accordingly, in some variations, increasing mucin release via intranasal stimulation may be performed as desired to help extend the comfortable wear time for contact lenses.

The stimulation may be delivered to the nasal mucosa. In some instances, the targeted area may comprise tissue innervated by the anterior ethmoidal branch of the nasociliary nerve. In some instances, the targeted area may comprise tissue innervated by the nasopalatine nerve. In some instances, the targeted area of the nasal mucosa may be superior to the columella. It may in some instances be near the inferior end of the nasal bone (i.e., near the interface between the nasal bone and the upper lateral cartilage). As such, the stimulus may be delivered between about 20 mm and about 35 mm into the nasal cavity of the patient, in some cases via an electrode between about 25 mm and about 35 mm into the nasal cavity of the patient. In other instances, the targeted area may be the columella. It may be desirable that the stimulus be delivered in the anterior portion of the nasal cavity, within the nostrils and anterior to the turbinates, and in some instances, at a location anterior to the middle turbinate, or at a location anterior to the inferior turbinate. The stimulus may be delivered at least partially through tissue of or near the septum, and it may in some instances be desirable to direct the stimulus such that a portion is directed toward the front of the nose. This may allow for selective activation of nerves in the front of the septum (e.g., the ophthalmic branch of the trigeminal nerve) while minimizing activation of nerves toward the rear of the nasal septum, which may reduce negative side effects that may occur from stimulation of nerves that innervate the teeth, and which may reduce rhinorrhea. It may also in some instances be desirable to direct the stimulus so as to reduce negative side effects that may occur from stimulation of the olfactory area.

The methods described herein may comprise intranasally delivering stimulation according to one or more treatment regimens. For example, to increase mucin release, stimulation may be delivered to a subject as needed and/or according to a predetermined plan. In some variations, it may be desirable that each round of stimulation is long enough to result in acute mucin secretion. Intranasal stimulation may be employed for about 30 seconds to about 1 minute to achieve mucin release. At 30 seconds of stimulation, some mucin release may be obtained while at 1 minute, the release of mucin may be more robust due to, e.g., the longer stimulation triggering a larger number of goblet cells to degranulate or the longer stimulation allowing more mucin to be released from goblet cells. It may in some instances take several or more minutes of intranasal stimulation to achieve mucin release. For example, in a patient with severe dry eye, it may take about 5 to 10 minutes to achieve mucin release, while in a patient with moderate dry eye, it may take about 3 to 5 minutes to achieve mucin release, while in a patient without dry eye, it may take only about 1 minute to achieve mucin release with particular stimulus parameters. In some variations, the methods described herein may comprise an initial round of stimulation that is longer than subsequent rounds of stimulation. The initial round of stimulation may in some variations be of a length sufficient to achieve mucin release in a patient with dry eye who has not previously been treated with electrical intranasal stimulation.

The initial round of stimulation may in some methods be performed under the supervision of a medical professional, while subsequent rounds of stimulation may be performed without supervision of a medical professional (e.g., at home). In some variations, the initial and subsequent rounds of stimulation may be delivered using different stimulators. These stimulators may be configured with different waveforms, and/or may have different physical configurations. For example, the initial round of stimulation may be delivered using a stimulator configured for hands-free use (e.g., may comprise nasal insertion prongs biased toward each other and/or a strap to hold the nasal insertion prongs in a subject's nose), while subsequent rounds of stimulation may be delivered using a stimulator not configured for hands-free use (e.g., a stimulator not comprising a strap and having parallel nasal insertion prongs). As another example, a stimulator used under supervision of a medical professional (e.g., for the initial round of stimulation) may be fully disposable, while a stimulator used without such supervision (e.g., for subsequent stimulation rounds) may be at least partially reusable.

In some variations, the intranasally delivered electrical stimulation may help to increase tear volume on the eye, e.g., by increasing the volume of the aqueous layer. Tear meniscus height (TMH) measurements can be used assess tear volume. For example, and as provided in Example 2 and FIG. 20, TMH measurements taken before and after the intranasal delivery of electrical stimulation demonstrated a statistically significant increase after intranasal application in both dry eye and control groups (p value equal to about 0.04 for both). In one dry eye subject with Sjögren's syndrome, intranasal stimulation increased tear meniscus height in the right eye by about 135% (95 μm to 225 μm) and in the left eye by about 82% (130 μm to 237 μm). Other findings in normal subjects demonstrated a significant correlation between TMH change and the degranulated to non-degranulated goblet cell ratio in MUC5AC stained cytology specimens; however, no significant correlation was found in dry eye patients. Overall, the impression cytology and TMH data demonstrate that intranasal stimulation triggers conjunctival goblet cell mucin secretion, and can provide a new approach to treatment of dry eye because it can stimulate aqueous tear production by the lacrimal glands as well as mucin secretion by goblet cells.

Additionally or alternatively, the intranasally delivered electrical stimulation may be useful in decreasing the concentration of inflammatory mediators in the tear film, or decreasing a particular type of inflammatory mediator, e.g., MMP-9 or IL-8, in the tear film. For example, as provided in Example 3 and FIG. 21, there was a decrease in MMP-9 concentration in the tear samples after the intranasal application of stimulation, which appeared to more be prominent in the dry eye group (decrease from 3372.37 pg/mL to 0.6 pg/mL). Data illustrating the decrease in IL-8 concentration as compared to controls after intranasal stimulation application is provided in Example 3 and FIG. 22.

The intranasally delivered electrical stimulation may be used to improve or treat various ocular surface diseases or various conditions of the eye. For example, the intranasal stimulation may be used to improve dry eye or ocular inflammation. In one variation, the intranasal stimulation may be used to improve dry eye or ocular inflammation associated with Sjögren's syndrome. In other variations, the condition of the eye is an unstable tear film or an unstable glycocalyx. Intranasal stimulation to increase mucin release for these conditions may optionally be used in conjunction with other therapies. In some variations, the intranasally delivered electrical stimulation is used in conjunction with one or more punctum plugs. In other variations, the intranasal stimulation may be administered in conjunction with application of one or more active agents, e.g., cyclosporine or lifitegrast, to the ocular surface. The one or more active agents may comprise one or more antibacterial agents, one or more anti-inflammatory agents, one or more antihistamines, one or more immunomodulators, one or more immunohistomodulators, or combinations thereof. Patients receiving intranasal stimulation may also be treated with topical treatments (e.g., artificial lubricants (e.g., lipid-based artificial tears), topical steroids, topical cyclosporine, topical lifitegrast, topical azithromycin, topical antibiotics (e.g., bacitracin)), topical antihistamines, oral antihistamines, oral antibiotics (e.g., oral tetracycline, oral doxycycline), nutritional supplements (e.g., fish oil, gamma-linolenic acid), and combinations thereof. In some variations, the intranasally delivered electrical stimulation is delivered in response to symptomatic need. In other variations, the intranasally delivered electrical stimulation is delivered to avoid a symptomatic need.

Studies conducted by the inventors thus far have captured the release of MUC5AC as the predominant mucin in the eye. However, there are other ocular mucins, as noted herein, and these mucins have different functions. Some function more as glue to keep the tears up longer (increasing tear film stability and tear film breakup time), while others encapsulate dust, allergens, bacteria etc. By encapsulating these “intruders,” mucins function together with the “glycocalyx” (FIG. 23) to prevent the intruders from directly contacting the corneal & conjunctival surface, which reduces the sensory input that would drive an inflammatory and/or histamine response. This in turn may decrease redness of the eyes, and decrease the concentration of inflammatory mediators on the eye surface. Accordingly, in some variations, intranasally delivered electrical stimulation may be used in combination with Restasis® Ophthalmic Emulsion (“Restasis”) (Allergan, Parsippany, N.J.) in the treatment of dry eye. To further explain, treatment first with Restasis may help to increase goblet cell density by reducing ocular surface inflammation. These goblet cells (as well those in the lacrimal gland) can then be triggered to release mucin. In this manner, treatment with Restasis and intranasal stimulation may be synergistic. This combined treatment may be beneficial in those individuals with severe dry eye and high levels of ocular inflammation.

Release of Other Tear Proteins

In patients with dye eye, the proper amount of tear proteins in the aqueous layer of the tear film may be lacking, in addition to, or alternatively to, mucin. The abnormal tear protein production may be due to systemic diseases (e.g., Sjögren's syndrome), medications, or other causes. In some variations, the methods described herein may use the application of intranasal stimulation, in the same manner as described for mucin, to increase other tear protein release into the tear film, e.g., the aqueous layer of the tear film.

Accordingly, methods for increasing secretion of tear proteins other than mucin on the ocular surface by intranasally delivering electrical stimulation to a subject are also described herein. For example, secretion of tear proteins such as lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, immunoglobulins such as IgA, IgD, IgE, and IgG, or combinations thereof, can be triggered by intranasally delivering electrical stimulation. The intranasal stimulation may be delivered for at least 5 minutes, at least 4 minutes, at least 3 minutes, at least 2 minutes, at least 1 minute, at least 30 seconds, at least 15 seconds, at least 10 seconds, or at least 5 seconds. In some instances, the electrical stimulation may be intranasally delivered for a duration of 3 minutes or at least 3 minutes. In other instances, the electrical stimulation may be intranasally delivered for a duration ranging from 30 seconds to one 1 minute, from 30 seconds to 1.5 minutes (90 seconds), from 30 seconds to 2 minutes (120 seconds), from 30 seconds to 2.5 minutes (150 seconds), or from 30 seconds to 3 minutes (180 seconds). Some variations of the method may include delivering intranasal stimulation to a subject for about 3 minutes to increase lysozyme and/or lactoferrin secretion into the tear fluid and onto the ocular surface. Referring to Example 5, data illustrating the increase in lysozyme and lactoferrin concentrations as compared to controls after intranasal stimulation application is provided. The electrical stimulation may be repeated any number of times using the same waveform or a different waveform.

Optimizing Intranasal Delivery of Electrical Stimulation

In general, aqueous tear production is readily sensed by a subject. However, the subject may not be able to identify when tear components such as mucin or other tear proteins are released. Accordingly, in addition to the intranasal delivery of electrical stimulation, the methods may comprise obtaining feedback relating to the efficacy of the delivered electrical stimulation by measuring impedance or an electromyogram (EMG) signal. Impedance may reflect the efficacy of the delivered electrical stimulation by indicating that sufficient current is able to flow from the stimulator into tissue. An EMG signal may reflect the efficacy of the delivered electrical stimulation because in some instances, neural stimulation of the anterior ethmoidal nerve may trigger muscle contractions of the orbicularis oculi and muscles on the cheek and of the nose as the patient controls an urge to sneeze. As such, EMG signals measured from facial muscles of the nose, cheeks and around the eyes (e.g., the orbicularis oculi) may provide feedback relating to the efficacy with respect to mucin and/or other tear protein secretion.

These forms of feedback, such as impedance or an EMG signal may be used, for example, to confirm that a stimulus is being effectively delivered for the intended stimulation duration. For example, this feedback may be used to confirm that the stimulus is being effectively delivered at the beginning of a round of stimulation and/or at one or more time points during the round of stimulation. When a round of stimulation has a particular length (e.g., at least about 30 seconds of stimulation), these forms of feedback may be used to confirm that the full duration of effective stimulation is delivered. As described herein, intranasal stimulation may be employed for about 30 seconds to about 1 minute to achieve mucin release. At 30 seconds of stimulation, some mucin release may be obtained while at 1 minute, the release of mucin may be more robust due to, e.g., the longer stimulation triggering a larger number of goblet cells to degranulate or the longer stimulation allowing more mucin to be released from goblet cells. As such, it may be desirable to confirm that stimulation is effectively delivered for the full desired duration.

The impedance and/or EMG signal may be measured using the same device that delivers the electrical stimulation. For example, the stimulators described herein may be configured to measure impedance and/or an EMG at or near the stimulus delivery electrodes. In other instances, the impedance and/or EMG signal may be measured using a separate device (i.e., not the same device as the device that delivers the electrical stimulation). For example, the impedance and/or EMG signal may be measured by a separate intranasal or extranasal device. In some variations, the extranasal device may comprise a nose strip comprising detection electrodes placed on the outside of the nose.

The methods for increasing mucin and other tear proteins on the ocular surface may further include identifying an optimal stimulation location for intranasally delivering the electrical stimulation. Finding the optimal stimulation location can be accomplished by guidance or training by the physician, as further described below. Techniques for identifying the optimal stimulation location can include impedance monitoring. Additionally or alternatively, the optimal stimulation location can be identified by obtaining feedback from an electromyogram (EMG) signal from a facial muscle near the nose, cheeks, or around the eyes (e.g., the orbicularis oculi). The impedance and EMG signals can be measured intranasally using the same device that delivers the electrical stimulation. In other instances, the impedance and EMG signals can be measured by an extranasal device. In some variations, the extranasal device comprises a nose strip.

The delivery of intranasal stimulation can also be accomplished via a treatment plan that optimizes one or more stimulation parameters, e.g., duration of stimulation, frequency of the stimulation waveform, and amplitude of the stimulation waveform, and/or finds the optimal location to stimulate in order to effect the desired response. As further described herein, the treatment plan may be formulated under guidance or training by a physician. One or more parameters of the electrical stimulation waveforms may be tailored or optimized to achieve release of mucin and other tear proteins from secretory vesicles of the lacrimal gland. The one or more optimized parameters can be selected from the group consisting of duration of stimulation, type of stimulation waveform, frequency of the stimulation waveform, amplitude of the stimulation waveform, pulse width of the stimulation waveform, and combinations thereof. In some variations, the one or more optimized parameters is duration of stimulation. It may be useful for the duration of stimulation to range from about 30 seconds to about 3 minutes, or from about 30 seconds to about 1 minute. Additionally or alternatively, the one or more optimized parameters is amplitude of the stimulation waveform.

Methods for treating dry eye are also described herein. The methods generally include intranasally delivering electrical stimulation to a subject afflicted with dry eye; obtaining feedback relating to the efficacy of the delivered electrical stimulation by measuring impedance or an electromyogram (EMG) signal from a facial muscle near the nose, cheeks, or around the eyes of the subject; formulating a treatment plan based on the feedback; and continuing intranasal delivery of the electrical stimulation according to the treatment plan, where the delivered electrical stimulation increases the release of a tear protein to treat the dry eye of the subject. Exemplary tear proteins include without limitation, mucin, lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E, and combinations thereof. The methods for treating dry eye can further include identifying an optimal stimulation location for intranasally delivering the electrical stimulation. Finding the optimal stimulation location can be accomplished by guidance or training by the physician, as further described below. Techniques for identifying the optimal stimulation location can include impedance monitoring. Additionally or alternatively, the optimal stimulation location can be identified by obtaining feedback from an electromyogram (EMG) signal from a facial muscle near the nose, cheeks, or around the eyes (e.g., the orbicularis oculi). The impedance and EMG signals can be measured intranasally using the same device that delivers the electrical stimulation. In other instances, the impedance and EMG signals can be measured by an extranasal device. In some variations, the extranasal device comprises a nose strip.

The delivery of intranasal stimulation can also be accomplished via a treatment plan that optimizes one or more stimulation parameters, e.g., duration of stimulation, frequency of the stimulation waveform, and amplitude of the stimulation waveform, and/or finds the optimal location to stimulate in order to effect the desired response. As further described herein, the treatment plan may be formulated under guidance or training by a physician. One or more parameters of the electrical stimulation waveforms may be tailored or optimized to achieve release of mucin and other tear proteins from secretory vesicles of the lacrimal gland. The one or more optimized parameters can be selected from the group consisting of duration of stimulation, type of stimulation waveform, frequency of the stimulation waveform, amplitude of the stimulation waveform, pulse width of the stimulation waveform, and combinations thereof. In some variations, the one or more optimized parameters is duration of stimulation. It may be useful for the duration of stimulation to range from about 30 seconds to about 3 minutes, or from about 30 seconds to about 1 minute. Additionally or alternatively, the one or more optimized parameters is amplitude of the stimulation waveform.

Other methods for treating dry eye may include determining whether a subject afflicted with dry eye is deficient in a tear protein on an ocular surface, and based on the tear protein found to be deficient, intranasally delivering an electrical stimulation to the subject, where one or more parameters of the intranasally delivered electrical stimulation is selected based upon the deficient tear protein, and where the intranasally delivered electrical stimulation is effective to increase release or the concentration of the deficient tear protein on the ocular surface. Exemplary tear proteins include without limitation, mucin, lysozyme, lactoferrin, tear specific prealbumin, caeruloplasmin, lacitin, lipophilin, and immunoglobulins A, D, G, and E, and combinations thereof.

In some instances, the methods may include determining a type of dry eye in a subject and intranasally delivering to the subject an electrical stimulation according to a treatment plan based on the determined type of dry eye, e.g., mild dry eye, moderate dry eye, or severe dry eye. Guidance and training may be offered by the physician so that the subject learns how to properly use the stimulator device according to their treatment plan.

EXAMPLES

Examples 1-3 below relate to a three-visit study consisting of one screening ophthalmological examination and two separate treatment visits for a total of 15 participants (10 with dry eye, and 5 normal). In one treatment visit, the participants were subjected to extranasal (sham) stimulation, and in the other visit, to intranasal stimulation. The types of stimulation were performed in randomized order.

Stimulation was performed for three minutes using a handheld stimulation device as described in FIGS. 4A-4E. For intranasal stimulation, participants were instructed to place the tips of the handheld stimulator into both nostrils simultaneously, and toward the top and front of the nose, as shown in FIG. 13A. The participants were instructed to place the tips of the handheld stimulator on the lower part of the nose (one tip on each side) for extranasal stimulation, as shown in FIG. 13B. At the end of the second and third visits, impression cytology (IC) was performed. IC refers to the application of cellulose acetate filter to the ocular surface to remove superficial layers of the ocular surface epithelium. Cells removed in this manner can then be subjected to histological, immunological, or molecular analysis. In this study, IC was performed on the bulbar conjunctiva of the right eye for PAS (Periodic acid-Schiff) staining and from the left eye for MUC5AC mucin immunostaining.

Results from the IC relating to the degranulation of goblet cells are described in Example 1. Furthermore, tear meniscus height measurements and tear fluid samples were collected before and after each stimulation, as described in Examples 2 and 3.

Example 1: Goblet Cell Degranulation

After staining, five images from each membrane were captured at ×20 magnification with a fluorescence microscope. In these images, the ratio of degranulated to non-degranulated GC densities (GCDs) was measured as a marker of mucin release/secretion. While non-degranulated GCs were typically well defined by their uniform size, intact cell borders, and intracellularly packaged mucins, degranulated GCs were characterized by disrupted cell borders and scattered mucin granules.

The goblet cell density data was analyzed using SPSS 20.0 for Mac (SPSS Inc., Chicago, Ill., USA). Prior to statistical analysis, data distribution was checked for normality. Because of the sample size, non-parametric tests were preferred in the analysis. The Mann-Whitney U test was used to compare differences between two independent groups. The Wilcoxon signed-rank test was used when comparing repeated measurements. A p-value of less than 0.05 was considered as statistically significant.

The results obtained from MUC5AC staining indicated that intranasal stimulation significantly increased the degranulated to non-degranulated goblet cell density ratio in the conjunctiva of subjects with dry eye as compared to normal/healthy subjects. The degranulated to non-degranulated goblet cell density ratio data is provided below in Table 1, and graphically represented in FIG. 14. Extranasal stimulation did not significantly increase degranulated to non-degranulated goblet cell density ratios for both groups. Specifically, the results obtained from MUC5AC staining indicated that the ratio of degranulated to non-degranulated goblet cell densities from subjects with dry eye was significantly higher after intranasal stimulation (4.71±4.48) compared to those taken at baseline (0.74±0.62, p<0.001) and after sham (extranasal) stimulation (0.57±0.54, p<0.001).

TABLE 1 A B C Base- Extranasal Intranasal P Values Groups line Application Application A-B A-C B-C Dry Eye 0.74 ± 0.57 ± 0.54 4.71 ± 4.48 0.333 <0.001 <0.001 (n: 20) 0.62 Control 0.75 ± 0.40 ± 0.22 1.99 ± 1.21 0.082 0.034 0.001 (n: 10) 0.52

Data obtained from the MUC5AC staining also demonstrated that goblet cell degranulation occurred in various areas of the conjunctiva on the eye (bulbar conjunctiva). IC samples taken from the inferior bulbar conjunctiva (IB) and temporal bulbar conjunctiva (TB) of subjects with dry eye and normal/healthy subjects showed an increase in degranulated goblet cell densities, as provided below in Table 2, and graphically represented in FIG. 15.

TABLE 2 Conjunc- Extranasal Intranasal Groups tiva Baseline Application Application Dry Eye IB (n: 10) 75.11 ± 53.57 44.39 ± 40.79  175.25 ± 112.22 IB (n: 10) 67.79 ± 62.11 52.28 ± 45.62 128.52 ± 86.01 Combined 71.04 ± 56.91 48.77 ± 42.46 149.29 ± 98.35 (n: 20) Control IB (n: 5) 99.06 ± 96.28 67.23 ± 29.45 124.87 ± 39.56 TB (n: 5) 69.73 ± 52.78 20.66 ± 13.69  85.76 ± 84.32 Combined 82.77 ± 71.47 41.36 ± 31.96 103.15 ± 67.58 (n: 10) IB: Inferior bulbar, TB: Temporal bulbar

Additionally, among dry eye participants, data obtained from the MUC5AC staining of IB and TB revealed a significantly higher ratio of degranulated to non-degranulated GCDs after intranasal stimulation compared to baseline and extranasal (sham) stimulation application (Table 3 and FIG. 16).

TABLE 3 B- C- Con- A- Extranasal Intranasal P Values junctiva Baseline Application Application A-B A-C B-C Dry 0.83 ± 0.79 0.41 ± 0.41 5.68 ± 5.48 0.142 0.014 0.012 Eye - IB (n: 10) Dry 0.66 ± 0.42 0.73 ± 0.61 3.73 ± 3.21 0.728 0.012 0.009 Eye - TB (n: 10)

Results obtained from the PAS staining were also statistically significant. As provided in Table 4 and FIG. 17, intranasal stimulation when compared to both baseline and extranasal stimulation demonstrated a significant increase in the degranulated to non-degranulated goblet cell density ratio in the conjunctiva of subjects with dry eye and in normal/healthy subjects. Specifically, there was a significant increase in the ratio of degranulated to non-degranulated goblet cell densities after the delivery of intranasal stimulation in dry eye subjects (2.02±1.41) compared to those taken at baseline (0.73±0.36, p=0.001) and after sham (extranasal) stimulation (0.69±0.39, p=0.001).

TABLE 4 B- C- A- Extranasal Intranasal P Values Groups Baseline Application Application A-B A-C B-C Dry Eye 0.73 ± 0.36 0.69 ± 0.39 2.02 ± 1.41 0.606 0.001 0.001 Healthy 1.06 ± 0.72 1.02 ± 0.76 2.38 ± 0.84 0.909 0.007 0.003 Subjects

Data obtained from PAS staining also demonstrated that goblet cell degranulation occurred in various areas of the conjunctiva on the eye (bulbar conjunctiva). IC samples taken from the inferior bulbar conjunctiva (IB) and temporal bulbar conjunctiva (TB) of subjects with dry eye and normal/healthy subjects showed an increase in degranulated goblet cell densities, as provided below in Table 5, and graphically represented in FIG. 18.

TABLE 5 B- C- Con- A- Extranasal Intranasal P Values junctiva Baseline Application Application A-B A-C B-C Dry 0.77 ± 0.34 0.79 ± 0.42 2.09 ± 1.34 0.802 0.026 0.029 Eye IB (n: 10) Dry 0.70 ± 0.40 0.58 ± 0.36 1.95 ± 1.55 0.432 0.014 0.01 Eye - TB (n: 10) IB: Inferior bulbar (Non-exposed zone), TB: Temporal bulbar (Exposed zone)

Example 2: Tear Meniscus Height (TMH)

During the treatment visits outlined above, tear meniscus height was measured by AS-OCT (Anterior Optical Coherence Tomography) (RTVue; Optovue INC., Fremont, Calif.) before and after stimulation applications. The study eye was the eye with the lowest tear meniscus height prior to the first stimulation application, or, if both eyes were equal, the right eye was considered the study eye.

As shown by the data in Table 6, which is graphically represented in FIG. 19, tear meniscus height revealed a statistically significant increase after intranasal application in both dry eye and control groups (p value equal to about 0.04 for both). In one dry eye subject with Sjögren's syndrome, intranasal stimulation increased tear meniscus height in the right eye by about 135% (95 μm to 225 μm) and in the left eye by about 82% (130 μm to 237 μm), as illustrated in FIG. 20.

TABLE 6 Groups Application Pre/Post Mean ± SD P Value Dry Eye Extranasal Pre 157.60 ± 57.59 0.138 Post 178.80 ± 58.57 Intranasal Pre 149.50 ± 69.76 0.041 Post 192.60 ± 47.34 Control Extranasal Pre 244.80 ± 63.24 0.080 Post  326.20 ± 118.27 Intraiiasal Pre 249.00 ± 75.13 0.043 Post  414.00 ± 112.12

Example 3: Tear Fluid Composition

During the treatment visits outlined above, tear fluid was collected before and after each intranasal and extranasal stimulation. Tear samples were collected using a microcapillary tube from the tear lake near the temporal canthus without touching the globe. Tear collection continued until a maximum of 5 μL was collected from each eye, or until 5 minutes had elapsed.

The tear samples were analyzed for a variety of factors and inflammatory mediators. Although not statistically significant, there was a decrease in MMP-9 and IL-8 concentrations in the tear samples after the intranasal application of stimulation, which appeared to more be prominent in the dry eye group. MMP-9 concentration data from subjects who revealed a decrease compared to controls after intranasal stimulation application are provided in Table 7 and in FIG. 21. Data illustrating the decrease in IL-8 concentration as compared to controls after intranasal stimulation application is provided in FIG. 22. Additional studies will be conducted to obtain data from more subjects.

TABLE 7 Dry Eye (n: 10) Control (n: 5) Intranasal Extranasal Intranasal Extranasal (n: 3) (n: 2) (n: 2) (n: 3) Af- Before After Before After Before After Before ter MMP-9 267.34 0.6 1336.28 37.5 1435.71 0.6 3372.37 0.6 (pg/mL)

Example 4: Goblet Cell Morphology

Data relating to morphological goblet cell (GC) changes before and after intranasal stimulation was obtained from a single center, single-arm, study that included 15 dry eye subjects (22 eyes). Intranasal stimulation was delivered using a handheld stimulation device as described in FIGS. 4A-4E.

Laser in vivo corneal confocal microscopy (laser IVCM) images were taken before and after approximately three minutes of intranasal stimulation application at the inferonasal area of the bulbar conjunctiva. GCs were analyzed and measured by ImageJ™ software. Three images from each subject were selected according to their quality and accuracy to be further analyzed by two masked observers. GCs were selected according to the following criteria: 50<area<150 μm², round or oval shaped, highlighted from the background, and well defined borders. All data are shown as mean±SD. Mean data were compared using a paired t-test. P values<0.05 were considered statistically significant.

Morphological analysis was performed for a total of 755 GCs pre- and 712 GCs post-application of the intranasal stimulation. Mean pre- and post-GC areas were 67.52±40.03 μm² and 58.72±31.16 μm², respectively. The mean change in area, 8.8±8.8 μm, representing a 13.03% reduction following use of the stimulation device, was statistically significant (p<0.001). Mean pre- and post-stimulation GC perimeters were 48.78±21.84 μm and 42.79±19.25 μm, respectively. The mean change in perimeter, 5.99±2.59 μm, representing a 12.27% reduction following use of the intranasal stimulator, was statistically significant (p<0.001).

Overall, a comparison of the laser IVCM images showed a significant reduction in GC area and perimeter within three minutes of stimulation, demonstrating a direct effect on GCs.

Example 5: Increased Secretion of Lysozyme and Lactoferrin

Increased aqueous tear production after intranasal stimulation was demonstrated in Example 2. In this Example, intranasal stimulation was also shown to promote release of other proteins from secretory granules in the lacrimal gland.

Fifty-five (55) dry eye subjects were enrolled in a single-arm study. Intranasal stimulation was delivered to the subjects using a handheld stimulation device as described in FIGS. 4A-4E for approximately 3 minutes. Tear samples (up to 10 μl) were collected using microcapillary tubes prior to and 5 minutes after use of the handheld stimulation device. Tear total protein concentration was determined using a micro-bicinchoninic acid protein assay and then the tear proteins separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) followed by Western blotting.

Data from the single-arm study is provided below as mean±SD (standard deviation). Mean differences in concentration (post-stimulation minus pre-stimulation) were evaluated by determining an equivalence margin and comparing the 95% confidence interval (CI) of the mean difference to the margin.

Mean pre-stimulation and post-stimulation total protein concentrations were 12.6±5.0 μg/μl and 11.9±4.0 μg/μl, respectively. An equivalence margin of ±2.52 μg/μl (20% of the pre-stimulation mean) was used to evaluate the equivalence of pre-stimulation and post-stimulation total protein concentration. The 95% CI [−2.11, 0.58], of the mean difference in total protein concentration (−0.76±4.85 μg/μl), fell within the equivalence margin. An equivalence margins of 0.20 μg/μl (20% of the pre-stimulation relative means) was used to evaluate the equivalence of the relative amounts of pre-stimulation and post-stimulation lysozyme and lactoferrin concentration. The 95% CI [−0.02, 0.09], of the mean difference in relative lysozyme concentration (−0.04±0.19), and the 95% CI [0.005, 0.22], of the mean difference in relative lactoferrin concentration (0.11±0.37), both fell within the equivalence margins. 

1-56. (canceled)
 57. A method for treating dry eye, comprising: intranasally delivering electrical stimulation to a subject afflicted with dry eye; measuring an impedance signal from a facial muscle of the subject, the impedance signal indicating an efficacy of the intranasally delivered electrical stimulation; and continuing, based on the efficacy of the intranasally delivered electrical stimulation, intranasal delivery of the electrical stimulation after measuring the impedance signal from the facial muscle of the subject, wherein the intranasally delivered electrical stimulation increases the release of a tear protein to thereby treat the dry eye of the subject.
 58. The method of claim 57, wherein the efficacy is indicated by muscular contractions associated with one or more facial muscles.
 59. The method of claim 57, wherein the efficacy is indicated by an amount current flowing from a stimulator to tissue of the subject, the stimulator configured to deliver the electrical stimulation.
 60. The method of claim 57, wherein the facial muscle is located near a nose, cheek, or around an eye of the subject.
 61. The method of claim 57, wherein the impedance signal is measured intranasally by a device that delivers the electrical stimulation.
 62. The method of claim 57, wherein the impedance signal is measured using an extranasal device.
 63. The method of claim 62, wherein the extranasal device comprises a nose strip.
 64. The method of claim 57, further comprising optimizing, based on the efficacy of the intranasally delivered electrical stimulation, one or more parameters of the delivered electrical stimulation.
 65. The method of claim 64, wherein the one or more parameters of the delivered electrical stimulation comprises one or more of a duration of electrical stimulation, a type of stimulation waveform, a frequency of the stimulation waveform, an amplitude of the stimulation waveform, and a pulse width of the stimulation waveform.
 66. The method of claim 64, wherein the one or more parameters of the delivered electrical stimulation includes a duration of stimulation.
 67. The method of claim 64, wherein the one or more parameters of the delivered electrical stimulation includes an amplitude of the stimulation waveform.
 68. A method for treating dry eye, comprising: intranasally delivering electrical stimulation to a subject afflicted with dry eye; measuring an electromyogram (EMG) signal from a facial muscle of the subject, the EMG signal indicating an efficacy of the intranasally delivered electrical stimulation; and continuing, based on the efficacy of the intranasally delivered electrical stimulation, intranasal delivery of the electrical stimulation after measuring the EMG signal from the facial muscle of the subject, wherein the intranasally delivered electrical stimulation increases the release of a tear protein to thereby treat the dry eye of the subject.
 69. The method of claim 68, wherein the efficacy is indicated by muscular contractions associated with one or more facial muscles.
 70. The method of claim 68, wherein the efficacy is indicated by an amount of current flowing from a stimulator to tissue of the subject, the stimulator being configured to deliver the electrical stimulation.
 71. The method of claim 68, wherein the facial muscle is located near a nose, cheek, or around an eye of the subject.
 72. The method of claim 68, wherein the EMG signal is measured intranasally by a device that delivers the electrical stimulation.
 73. The method of claim 68, wherein the EMG signal is measured using an extranasal device.
 74. The method of claim 73, wherein the extranasal device comprises a nose strip.
 75. The method of claim 68, further comprising optimizing, based on the efficacy of the intranasally delivered electrical stimulation, one or more parameters of the delivered electrical stimulation.
 76. The method of claim 75, wherein the one or more parameters of the delivered electrical stimulation comprises one or more of a duration of stimulation, a type of stimulation waveform, a frequency of the stimulation waveform, an amplitude of the stimulation waveform, and a pulse width of the stimulation waveform. 